Maggie's Farm

I majored in Statistics in college (with a minor in English Lit), but my stats sophistication is a bit rusty now. But it's not so rusty that I do not raise my brow at any latest stats reported in medicine, or especially in Psychiatry - and especially genetic studies.

As Gene Expressions points out, it's partly because a p-value of 0.05, commonly used in such studies, is unrealistic for these things. It's straight out of How to Lie with Statistics, which is essential reading for all high school students.

As the man says, if there is a genetic serotonin link with trauma and depression, it has yet to be proven.

In his second post on the topic, Why are most genetic associations found through candidate gene studies wrong? he makes the key point:

For nearly all diseases, reproducible associations have small effect size and are only detectable when one has sample sizes in the thousands or tens of thousands (for many psychiatric phenotypes, even studies with these sample sizes don't seem to find much). The vast majority of candidate gene association studies had sample sizes in the low hundreds, and thus had essentially zero power to detect the true associations. By the argument above, in this situation the probability that a "significant" association is real approaches zero. The problem with candidate gene association studies is not that they were only targeting candidate genes, per se, but rather that they tended to have small sample sizes and were woefully underpowered to detect true associations.

While I find the field of behavioral genetics to be as fascinating as anything else in this world, I always read the latest gene-behavior studies with the highest skepticism. (Do I think real Bipolar Disorder has some provable genetic underpinning? Yes, I do, even though I do not think it has been adequately proven yet. But not much else genetic in Psychiatry has been adequately proven in my view. Schizophrenia maybe, IQ almost certainly, but possibly not homosexuality, or depression, or alcoholism.

The trick to getting papers published is to run your numbers so they show something. It's not rocket science if you know how to do it: just look at the climate studies. (Even Einstein fudged his math. He happened to turn out to be right, though, as far as we know today.) Science is about hypotheses, not Truth.

Many of us here have discussed how much can be learned from failure, and how relatively little can be learned from success.

Thus it is gratifying to see the child of Memphis and legendary hedge fund owner Paul Tudor Jones delivering a 9th Grade graduation address to the "Buckley Boys" in which he declined to discuss the recommended sanctimonious topic of "service" and instead spoke about the value of failure.

Good on him. Almost all of my wisdom has come from my errors and failures - whether personal or professional. Read his speech, and invite your kids to read it too.

No good deed goes unpunished.

Well, that is surely not always true, but with the economic downturn, the charity medical clinic at which I volunteer one day per week has seen a sharp upturn in lawsuits against us Docs and the clinic this year.

The medical defence lawyer we have now engaged (we have had no complaints or suits for 10 years until January 2009) tells us that we should now regard each patient as a potential enemy. (Our clinic's founding Christian philosophy is to regard every patient as a friend and neighbor.) 

He tells us that our notes must be guided by the principle of CYA (your notes are legal documents, not medical reminders as we had thought) and that every decision a doc makes contains some basis for a suit in the hands of a hungry lawyer because all medical decisions are judgement calls and every situation is unique.

He also told us that recessions tend to see more suits against doctors because more folks are looking for cash, and much more so in charity settings. Plus the tort lawyers are hungry too - but they always are. He also advised us to refuse to treat any patients with substance abuse histories for our protection - other than alcohol.

He actually said "Do not be kind. They will screw you whenever they decide to." He has been around the block a few times.

I do not like this at all. A Psychiatrist/Psychoanalyst cannot do the job under such conditions. Furthermore, I can not and will not endure any relationship in my life without mutual trust. I am considering resigning (even though I was one of the founders of the place) and finding some other outlet for my charity. Maybe prison work, where you can safely begin with the assumption that everybody is a liar and cheater and working the system - and take it from there.

My position on the Board, plus my volunteer time (all unpaid) doubles my legal liability. I just want to do my best, tithe and double-tithe my time, and avoid hassles that do not fit into my life - and legal fees that I cannot comfortably afford.

And no, I would never work for ObamaCare. Never. I did not go into medicine to be a government employee. I went into medicine to work for my patients, doing my best, with no intention of looking out for lawyers.

Steyn on medical care and the nanny state. Great piece. One quote:

...there is a cost to governmentalizing every responsibility of adulthood – and it is, in Lord Whitelaw's phrase, the stirring up of apathy. If you wander 'round Liverpool or Antwerp, Hamburg or Lyons, the fatalism is palpable. In Britain, once the crucible of freedom, civic life is all but dead: In Wales, Northern Ireland and Scotland, some three-quarters of the economy is government spending; a malign alliance between state bureaucrats and state dependents has corroded democracy, perhaps irreparably. In England, the ground ceded to the worst sociopathic pathologies advances every day – and the latest report on "the seven evils" afflicting an ever more unlovely land blames "poverty" and "individualism," failing to understand that if you remove the burdens of individual responsibility while loosening all restraint on individual hedonism the vaporization of the public space is all but inevitable. In Ontario, Christine Elliott, a candidate for the leadership of the so-called "Conservative" party, is praised by the media for offering a more emollient conservatism predicated on "the need to take care of vulnerable people."

Look, by historical standards, we're loaded: We have TVs and iPods and machines to wash our clothes and our dishes. We're the first society in which a symptom of poverty is obesity: Every man his own William Howard Taft. Of course we're "vulnerable": By definition, we always are. But to demand a government organized on the principle of preemptively "taking care" of potential "vulnerabilities" is to make all of us, in the long run, far more vulnerable. A society of children cannot survive, no matter how all-embracing the government nanny.

What's my view? I am in favor of providing help with medical costs for the poorest and most helpless, but we already have that. It's called Medicaid. Furthermore, the charity clinic I work in one day a week will see anyone who makes under $50,000/yr and who lacks insurance, on a sliding fee scale. We will see nobody for nothing, though: that would be degrading both to patient and to the docs. (Such clinics are a good example of "civic life.")

I know there seem to be more people around today who long for a parental State than there were 20 or 30 years ago. I worry that they do not know that they are selling their freedom, dignity, and can-do spirit - literally their American birthright - for a bowl of lentils.

Via a colleague from a patient in his 40s this afternoon: "With my unemployment now with 23 weeks, plus the State's 12 weeks, and the federal 18-week extension, I figure I can begin looking for a job in November. Since my wife got laid off later, she can wait until December or January. We're both burned out and need a break from work. She's been getting job offers, but there's no way she would take one now. And keeping our income down will help my youngest get a scholarship."

I didn't know this new world was offering Sabbaticals For All. How do I get mine?

Insty notes that one would think that California legislators would have more to worry about than day care center diets. Maybe not.

They want 2 year-olds to eat vegetables and skim milk to deal with the "obesity crisis." What they apparently forgot is that the natural diet of 2 year-olds is sweet, fatty Mother's Milk.

And what they probably never bothered to learn is that normal brain development depends on getting the right fats. Myelenization of the brain continues through adolescence. Whole milk is the right thing for kids, whether it's Mom Juice or Cow Juice.

It's tough for doctors because we are often held responsible for people who either do not want, or do not accept, our help and advice. But, as long as their name remains on our rolls and as long as we persist in trying to be constructive, the lawyers can get us.

I have been burned several times by keeping them on the rolls in the charity clinic, only to be sued by them eventually for not doing a better job "taking care of them." What? I am not a professional mother and I do not "take care of" anybody. I am a doctor, not a caretaker and, despite the modern lingo, not a "care-giver" either.

Like all doctors,  I try to work with my patients - and do not take care of them, or I to try to bring them around to where I can work with them.

If I were more self-protective, I would not even try and would just say "I cannot help you. Good bye," but that is not my medical tradition. My medical tradition is that you are a friend to your patients, whoever they are.

Novalis presents such a case. More practical docs than I am would just throw them out of the office. However, after being punished and hassled legally several times by going the extra mile, my heart grows harder. 

Indeed, good deeds often are punished and yes, it does lead to some bitterness especially when it is performed on a charity basis. I have never been sued or hassled by a private, self-paying patient. 

Mnemosyne was impregnated by Zeus for nine consecutive nights, thus producing the nine muses. Among other things, she was a goddess of memory.

The number of muses increased over time from the original three. Poetic license and creeping specialization. I had been looking up Euterpe, the muse of music and of lyric poetry, called "the giver of delight." The muse of song, but got sidetracked on the general topic of the Muses.

I posted briefly on inspiration the other day, and we had "Sing, Goddess..." recently. It remains fascinating to me that our mental creations seem to come from "elsewhere," to the extent that we can imagine that they come from a supernatural source.

In my line of work, we say that such things come from the "preconscious" or the "unconscious," but that's not much different from saying they are gifts of a Muse.

Whenever a preacher says "May the words of my mouth, and the thoughts and meditations of my heart, be acceptable to You," he or she is echoing the classical plea to the Muses. Our civilization remains a Greek one.

This site tries to personalize the Muses.

Image is Dante Gabriel Rossetti's Mnemosyne (1881)

Kealey's talk which we posted yesterday is a wonderful revelation. It confirmed much of what I suspected in the back of my mind but never focused on or thought through. I would like to read his book.

Many things become sacred cows without any evidence for their benefit. Most famous example: the incredibly expensive Head Start program, whose benefits disappear after a year. The rug rats would be better off banging around the neighborhood or the fields and swamps, learning how to educate and entertain themselves. Just get rid of the damn TV.

These "programs" become sacred cows via their income constituencies and their penumbra of virtuousness - not their effectiveness.

The infantile fantasy of government as source of virtue is an insidious one because government is only about one thing: power, and the mediocrities who seek it and the money that accrues to it to maintain that power.

Is government funding for research little more than welfare for PhDs? Possibly. In my field, you would be amazed by the stupidity of most of the government research grants which are paid for by the taxes of modest, hard-working folks who would rather worry about their families than seek power over others. Must be fun to appear benevolent with OPM.

Cui bono?

In the Q&A, Kealey astutely points out that people seek ways to proclaim "I am a good person," and that being concerned about global warming is (or was?) today's fashionable version, just as eugenics was at the turn of the century, socialism in the 1930s, being a Dem during Reagan, and flag pins and bumper stickers after 9-11. Symbols and attitudes as effortless, non-sacrificial fashion statements.

Althouse posting at Insty on Internet Addiction.

That's the stupidest thing I have heard of yet today - so dumb it makes my hair hurt, as Imus would say. So dumb I won't even waste any virtual ink to bother to explain why.

I prefer this piece in NY Mag: In Defence of Distraction.

Editor's Note: Dr. Helen covers this "addiction" nonsense.

Shrinks debate putting Bipolar Disorder into the Psychosis category.

It's all a tempest in a teapot for me. All of our diagnoses in Psychiatry are of dubious validity. They have two purposes: 1) Something to write on an insurance form and 2) a starting point for research to find out if they make any sense.

I do not even think that Schizophrenia is a "disease" per se. It's a handle for a lot of different strange things that we understand poorly.

I hate studies of happiness because 1) I think happiness is fleeting 2) Everybody's happiness is different 3) I think good cheer and happiness come from within and from a clean conscience - not from without and, 4) I don't think life is or should be all about happiness anyway: I think it is meant to be made of sterner stuff than that...but that's me.

Therefore, I believe that "the good life" is not a one-size-fits-all shoe. For some, it's about being half in the bag on a mountaintop. For some, it's struggling with impossible math problems; for some, it's exerting minimal effort. For some, it's about having good relationships, but many folks don't give a darn about that. "Happiness" is a useless concept and, to me, a "good life" means nothing more than an honorable, responsible Christian life, with minimal jail time, and some golf and tennis and a good man in it but, again, that's just me.

Joshua Shenk has a piece in The Atlantic on the now-72 year-old Harvard longitudinal study.  He begins:

Last fall, I spent about a month in the file room of the Harvard Study of Adult Development, hoping to learn the secrets of the good life. The project is one of the longest-running—and probably the most exhaustive—longitudinal studies of mental and physical well-being in history. Begun in 1937 as a study of healthy, well-adjusted Harvard sophomores (all male), it has followed its subjects for more than 70 years.

Read Shenk's piece, and tell me what you think. David Brooks wrote a commentary on the Shenks piece, in which he says:

The study had produced a stream of suggestive correlations. The men were able to cope with problems better as they aged. The ones who suffered from depression by 50 were much more likely to die by 63. The men with close relationships with their siblings were much healthier in old age than those without them.

But it's the baffling variety of their lives that strikes one the most. It is as if we all contain a multitude of characters and patterns of behavior, and these characters and patterns are bidden by cues we don't even hear. They take center stage in consciousness and decision-making in ways we can't even fathom. The man who is careful and meticulous in one stage of life is unrecognizable in another context.

Shenk's treatment is superb because he weaves in the life of George Vaillant, the man who for 42 years has overseen this work. Vaillant's overall conclusion is familiar and profound. Relationships are the key to happiness. "Happiness is love. Full Stop," he says in a video.

In his professional life, he has lived out that creed. He has been an admired and beloved colleague and mentor. But the story is more problematic at home. When he was 10, his father, an apparently happy and accomplished man, went out by the pool of their Main Line home and shot himself. His mother shrouded the episode. They never attended a memorial service nor saw the house again.

He has been through three marriages and returned to his second wife. His children tell Shenk of a "civil war" at home and describe long periods when they wouldn't speak to him. His oldest friend says he has a problem with intimacy.

Even when we know something, it is hard to make it so. Reading this essay, I had the same sense I had while reading Christopher Buckley's description of his parents in the New York Times Magazine not long ago. There is a complexity to human affairs before which science and analysis simply stands mute.

Ed: Related, see some of our previous posts on the topic:

Are we happy yet?

The Aristocracy of the Human Spirit: Freedom vs Happiness

Money and Happiness

Huxley's Brave New World at 75

 Do Americans expect too much of marriage?

Happiness for Sale! No brain, no pain.

Grumpy. Are Americans hard to please, or do we just love to bitch?

One of us quoted Dylan recently, who said something like "You got to take your inspiration wherever you can get it."

And we recently posted the lines which begin "Sing, Goddess...." Thus acknowledging that the Goddess is the author, not the man. The man is the messenger.

It reminds me of what my pastor once said to me when I asked where the preaching came from: "I stand up there, and the Holy Spirit uses me. It just flows out. I have nothing to do with it."

The definition of "inspiration" is "the immediate effect of God or gods." How wonderful is it that the word doubles as the medical term for inhaling, and that "expiration" doubles for exhaling and for death?

Recently stumbled upon Furious Seasons. It's a shrinkology-related but far from shrinks-only site. Provocative.

The guy is a patient and a journalist, not a shrink.

I have posted numerous times here about the role that infantile wishes and hopes can play in the lives of those who are otherwise adults. We all must have hopes and dreams, and we all must have many of them dashed to become real, serious adults.

Real serious adults know all about the futility of wishful thinking, Santa, the Tooth Fairy, the Easter Bunny - and the free lunch.

Hoven at American Thinker has a post up about Wishful Thinking in politics. As salesmen, politicians are all about appealing or pandering to wishful thinking. He begins:

There's the old joke about an economist's plan to get out of a pit he was thrown into: "First, we assume a ladder."  There has been a whole lot of assuming going on, from alternate energy to non-harsh interrogations.

Megan addresses the issue of primary care docs. Fact is, internists are sort of our routine GPs now. It's not possible to be an old-time GP any more, doing obstetrics, pediatrics, minor surgery, cardiology, cancer, neurology, psychiatry. You couldn't keep up, for one thing - and no insuror would cover you. The closest things we have to real GPs today are ER docs.

The comments on her post are interesting.

The news mills are ginning up yet another medical crisis storm these days in an effort to pave the way for gummint medical care by the same good folks who run the DMV and the post office. They seem to imagine a problem with cost, access, and insurance. Maybe we are a nation of crybabies, because we have the best medical care in the world with which to pamper our so-called precious selves.

It's time we got beyond that self-love, and cared about the Greater Good. I have a few simple, rational, Utilitarian solutions.

Cost: Cost is driven by technology and modern pharmacology, cancer treatment, crocks (people obsessed with their health), gomers ("gomers go to ground"), and futile, guilt-driven end-of-life treatment for annoying old or sick relatives. The cost of American medical care can be dramatically reduced by forbidding all cancer treatment other than Oxycontin and at-home 10-gallon morphine pumps, all medical treatment for those over 57 (the children are our future!), all CT and MRI scans, all blood tests, and all medicines other than friendly, holistic, herbal organic ones. No more vaccinations - they cause Autism. No more antibiotics - everybody knows that they make people sick. Eliminate Dermatology (just stay out of the sun, people). Eliminate Opthalmology (bad eyesight is from masturbation - it's your own fault). Eliminate Psychiatry (mental illness is socio-political mind control). Eliminate Urology (do you want a #3 gauge tube stuck up your urethra?). Eliminate Surgery - it is physical assault on comatose victims. Eliminate Neurology - it's just nerves.

Access: Doctors are like waterfront trade unions: they limit their numbers to keep their payments high enough to join country clubs, to buy boats, and to take vacations. My idea: anybody who gets a C or better in Organic Chem is automatically admitted to a government medical school. Lots of good, caring people are weak in math and chem and bio and stuff, but that's who we need more of. My medical school flunk-out rate was 18%: what a waste of talent. Plus there are too many Jews and Asians in medicine anyway, and too few people of color or of gender identity diversity. So, with this increase in the numbers of docs, fees could go down to $5 per office visit and the docs who don't like it can open dry cleaning shops, cigar shops and wine shops like they do in Canada.

Insurance:  Medical insurance is a dumb idea. Why expect your neighbor to pay your medical bills when they will be so low under my plan anyway? They will be cheaper than your garbage pick-up, your newspaper subscription, your cigarette costs, your car payment or your monthly payment for your big screen TV. (Did you ever notice how nobody complains about the cost of their TVs, computers, or Life Insurance?) Or just save your money if you want and die quietly without complaint, dude, and make space for the next generation. Too many people on the planet and, let's face it, life isn't all it's cracked up to be anyway. A vale of tears and toil, a tale told by an idiot, full of sound and fury, signifying nothing. What's the big deal about death? Didn't your parents teach you that life is a bitch?

Interesting link by our News Junkie last night re people who think of themselves as "good." That link led to Ryan Sager's The Al Gore's Fraggin' Giant Mansion Effect. A quote:

If you’re too-well-satisfied that you’re a good greenie, you’re more willing to cut yourself slack when you hurt the environment.

Call it the Al Gore’s Giant Fraggin’ Mansion Effect.

According to a new study in Psychological Science, humans engage in a process called “moral self-regulation.” Basically, we’re constantly calculating the trade-off between being able to see ourselves as good people and the cost of engaging in all that non-advantageous goodness.

You might expect that being prompted (primed) to think of yourself as a good person would make you more altruistic or moral — but, in fact, the exact opposite appears to be the case.

Read the whole thing. I have too many reactions to this to post briefly, but my first thought was that I have seen this many times. (See Obama's Earth Day flights burn 9000 gallons of fuel.) The process goes far beyond Greenieism. Many people play tricks with themselves in order to have their cake and eat it too.

The NJ summed it up perfectly: "They seem to think they get a pass because they're good." It reminds me of our recent QQQ from PJ O'Rourke: "Everybody wants to save the world but nobody wants to help Mom with the dishes."

It's important to most people to view themselves as virtuous. Cheap and easy virtuousness (recycling, donating to charities, volunteering, serving on committees, etc) is often used by people, consciously or unconsciously, to excuse or to compensate for their sins and crimes (eg not reporting cash income, cutting corners, patronizing massage parlors, spreading gossip, lying, etc). In my view, honest people wrestle with sin rather than playing the "moral self-regulation" game.

How many criminals have been described as "pillars of their community,"  "great guy, always kind and generous," "everybody loved him," "a great supporter of civic causes"? Lots of them.

I am not talking about guilt-driven "conspicuous virtue" here, like the cheating guys who bring their wives roses - I am talking about the secret compromises people make internally so as not to mentally suffer from their feelings of sinfulness and hypocrisy.

I could go on and on on this topic. More later, maybe.

Photo: John Gotti, the "Dapper Don," once a pillar of his community of Howard Beach, Queens, NYC, generous donor to his church and kids' sports, and an avid recycler with a deeply caring interest in the always-Green trash-hauling and recycling biz.

I had lunch yesterday with a friend who runs a fund at Fidelity in Boston. She mentioned how many friends and acquaintances she has who had been - or had felt - wealthy but are now in desperate straits.

They had overpaid for grand houses in Cambridge and Chestnut Hill, and then did million-dollar renovations and extensions. They overpaid and leveraged themselves further by buying weekend houses in Maine, Nantucket, Westport or Marion. They bought expensive cars, and paid $300,000 on interior decorating. Wherever they travelled, they stayed at the Four Seasons unless they were golfing in Ireland or Scotland. They had had the sort of blind optimism that led them to believe that $1.5 million bonuses would continue forever. They saved next to nothing. And these are not stupid people: these are bright folks, Ivy League MBAs who know math - but unwise.

She told me about somebody like that in their late 30s whose family has had to move into her parents' house in Natick, and who has their two homes on the market.

We spoke of the time-honored and traditionally-admired Yankee virtue of not living within your means, but below your means. We spoke about the Yankee virtues of "making do," "going without," and giving to others. We spoke about ostentatiousness and conspicuous consumption. We pontificated about whether getting and spending represented an emotional or spiritual emptiness, or a hollowness in a part of American culture. We reflected on whether the childish "I want..." had replaced more durable and mature motives and life guidelines. We touched on what God wants from us, as we always do when we are together. We remembered the old-time Yankee pride in driving old, beat-up station wagons to the tattered old WASPy yacht club in Marblehead. We remembered the old-time Yankee pride in owing nothing, and the pride and freedom that confers: owning your life.

Then, after an excellent no-carb lunch and with a couple of chardonnays under our belts, we went shopping.

Photo: Simple but charming living quarters from Sipp's snarky piece on homes: I'm going to say somethng rude now.

I opted out of Medicare years ago. I felt morally torn about doing so, but finally my bookkeeper refused to do any more of their paperwork. That settled it.

My compromise was to institute a generous sliding fee scale for Medicare-aged folks. (My general policy is to never decline a referred patient because of money.) From a young Doc, in the WSJ:

Here's something that has gotten lost in the drive to institute universal health insurance: Health insurance doesn't automatically lead to health care. And with more and more doctors dropping out of one insurance plan or another, especially government plans, there is no guarantee that you will be able to see a physician no matter what coverage you have.

Consider that the Medicare Payment Advisory Commission reported in 2008 that 28% of Medicare beneficiaries looking for a primary care physician had trouble finding one, up from 24% the year before. The reasons are clear: A 2008 survey by the Texas Medical Association, for example, found that only 38% of primary-care doctors in Texas took new Medicare patients. The statistics are similar in New York state, where I practice medicine.

More and more of my fellow doctors are turning away Medicare patients because of the diminished reimbursements and the growing delay in payments.

People vary enormously in their levels of life functioning, talents, and life-mastery, don't they? Nature confers variety - not equality - because variety is essential for a species to survive when circumstances change.

You could make a graph of the people you meet by rating their functioning in various areas on a 0-10 scale:

- Social skills, personal charm, manners, graciousness, general behavioral appropriateness and adaptability, dignity and demeanor; 
- personality style and temperament;
- IQ, intellectual skills and depth, range of knowledge; 
- physical skills;
- morality and strength of character, tendency to blame or to assume responsibility, and desire to assume responsibility; 
- ability to delay gratification/impulsivity;
- coping abilities under stress, pressure, pain and strong emotion;
- sense of humor;
- emotional stability, predictability, and maturity;
- judgement, planfulness, and decision-making;
- capacity for kindness, thoughtfulness, empathy and love vs self-centeredness;
- degree of "neuroticism;"
- special talents and interests;
- reliability, and trustworthiness;
- work ethic, energy, persistence, perseverance despite fear or difficulty;
- realism vs. naivete and childishness;
- independence, ambition and initiative;
- risk tolerance, adventurousness and aggressiveness;
- curiosity and range of knowledge;
- self-discipline;
- creativeness, imagination and cleverness 

...and so forth.

Feel free to graph yourself on these items - but do not call me if you feel depressed afterwards. We are supposed to identify our weaknesses, and to work on them if we feel motivated to do so.

Most of these qualities are subsumed under what we term "ego functions." (We shrinks use the term "ego" to refer to the tools we have to mediate between our "inner" selves and external reality, not the casual, non-technical meaning of "self-centeredness.") My well-exercised shrink brain tends to measure these things about people on autopilot, even when I try to turn it off. (I also "take my own inventory" frequently with pitiless honesty, and I have my own share of frailties.)

Nevertheless, all of these factors feed into one's ability to construct a life in a free country. Yes, a life must be constructed like a building, but usually with changes along the way.

Fortunately, the world offers things for almost every person to do - and in which to excel if they wish - regardless of how their unique graph maps out. It's generally the pattern of strengths and weaknesses that matters, not the overall "score."

However, I can say, after many years of careful observation of humans, that the folks I have known with the highest overall scores have been military officers, physicians, ranchers, and investment bankers. Don't argue that with me - that's just my own limited life experience.

Many of the most interesting people I have known have very high scores in some areas and very low ones in other areas. That might be part of what makes people interesting. Perfect scores would be the most boring person in the world.

But that doesn't matter, because in America we all play the cards we are dealt, and we all get to make the most of what we have - and to try to develop where we are lacking if we want to, and we get to play out our hand in whatever way we chose, given the heavy constraints of mean old Mr. Harsh Reality (including the chance to write run-on sentences).

A repost from a couple of years ago -

This is a real American story about a true American idol. It's also a story about home-town America, which is, sadly, a disappearing way of true community life.

I met with an 83 year-old fellow the other day for a consultation. He was recovering from a heart attack from which he almost died ("I thought it was just a bad stomach ache but my wife didn't like the way I was sweating.") and a stent.

His cardiologist felt he was depressed, as often happens after serious cardiac events, especially with men.

He told me a little story, but first, a bit about him: Irish, retired policeman, living with his frail wife (a retired book-keeper) in the Boston suburb where he was born - same neighborhood and across the street from the house he grew up in (remembers horse-drawn fire engines down the block); daily Mass; in the church choir ("We sang at the Vatican in 1972 and we are proud of that."); plays trombone ("poorly") in his firehouse marching band; five attentive, devoted kids and 14 grandkids within twenty miles; does every charity thing he can find including Meals on Wheels (even though "I think I am older than most of the people I deliver to"); belongs to his local Vets organization; a WW2  Vet - a gunner in a B-26 Martin Marauder with the 320th Bomber Group of the 12th (Army) Air Force, in Italy: "When flak hit the airplane, it sounded like somebody shaking a bucket of gravel."

Says "We weren't scared. We already knew we would die in this war to save Europe, and we were sort of OK with that, but we were damn well gonna get all of the bad guys we could, first. Heck, we were just kids, looking back now, and full of beans and bacon."

His story: "I was at a wake of a friend a few weeks, ago, drinking and partying of course, and up comes somebody I knew from second grade at St. Anthony's. He says "You need to join our lunch group. We meet once a month at .... restaurant in the back room." I felt flattered to be invited, so I went. My God, I met folks I hadn't seen in years, all from the same home neighborhood - the --th Ward. About 25 guys, retired doctors, teachers, lawyers, mailmen, firemen, mostly moved out of my home parish but all still in town. Somehow lost track of them. A great joy, since so many friends still in my neighborhood have died. We took about 15 minutes to eat, and talked for two hours and had a few beers. I almost said we should meet once a week, but it wasn't my place as a newcomer. I need to stay active, Doctor, because my wife needs me. Doc, life is good, and I'd like to make a few more of these lunches before the good Lord takes me."

God Bless America. And God bless him. No, he did not need me as a shrink: I need some more of what he's got: the true American spirit. One secret: we psychiatrists are more blessed by what we get from our patients than by what we have to give.

Details altered just barely enough for confidentiality (not that he would mind, but he would be embarassed by admiration and attention) - but not the 320th BG - that is accurate.

Yesterday morning's NJ post on "Quality Care" from the WSJ was enlightening, and just gives me one more reason to stay away from Medicare (besides the fact that they pay me peanuts, and that their paperwork requirements are over my head and take more time than my patients take).

I see how government "Quality Care" works: the academic medical experts take a vote, and that becomes "Quality Care." That's not medical care: that's government policy. Forget the individual patient and his or her unique situation, forget the Doc's experience and skills and insight, forget the Doc's judgement, forget the fact that academic Docs aren't always practical, forget that next week's new data will completely alter the information at hand. Just Follow The Rules and stay out of trouble.

I have seen plenty of cases go bad in the hands of young Docs who strictly follow the rules. It's not a good example of that, but when I was a resident one of "the rules" of the time included strict limits on the use of pain-killers, even for terminal cancer patients. Didn't want them to become addicts, you know. They forgot that pain relief remains one of a handful of the greatest blessings medicine has bestowed on humanity (along with anesthesia, antibiotics - and Lexapro).

One of the best things about seasoned physicians is that they are a cranky bunch who do not take orders, who think for themselves, who feel that rules are made to be broken, and who do not like to take crap from anybody - especially anybody in "authority". Your patient comes first, or you are nothing. There is a "House" inside every Doc. In most lines of work, you can't get away with that sort of attitude.

When government gets involved in things, they tend to screw them up. The article's example of high blood sugars in the ICU was a perfect example. Even I, who have not cared for ICU patients for more than a decade, know that tight sugar control for critical patients is insane and dangerous. Not only that, but it doesn't matter: if the patient survives and gets healthy, a few days of higher sugars with a good margin of error will not have hurt them one darn bit. But I am a Doc with a practical mind.

Expertise always has to be taken with a grain of salt, and government-emitted expertise with a tablespoon-full. I am not disparaging expertise, which I respect enormously. I just distrust the combination of expertise with power over others: anointed experts who want power instead of simply to educate give me the willies.

Non-"experts" often have loads of common sense. We take an ancient oath, too.

Ed. note: Somewhat related: Socialized medicine: A warning from across the pond

Readers know that I am always skeptical about labelling and diagnosing people with whom I have not sat and talked for quite a while. Every time a mass murderer goes on a rampage, though, we shrinks come out of the woodwork to opine.

Our friend Shrinkwrapped discusses the Binghamton murders in terms of Narcissistic pathology. It's a good, clear description of pathological narcissism (we posted on the "Narcissism Epidemic" last week) but, in one way, I find it disappointing.

Here's the problem: the world is full of pathological narcissists. Many of them are very successful in worldly terms (if unsuccessful in relationships). Most or all of them endure painful humiliations, failures, and disappointments in life (as does everybody - but narcissists are less resilient in the face of these things and are more likely to sink into rage or depression). Assuming that SW's speculative diagnosis is correct in this case, it still has no predictive power.

Thus my speculative, highly professional diagnosis of killers - whether mass killers or not or whether narcissists or not - is that they have a screw loose. Everybody feels like killing somebody sometimes, but very few do (in Western civilization).

SW did highlight something I had been thinking of writing about anyway. He says:

The Narcissist has a damaged self.  When the environment (esp other people) support his self esteem, he does relatively well.  He may be charming and charismatic and appear to be self assured and in command of himself.  However, should the other fail him the pain of the assault on his self esteem is destabilizing. 

 True (although I would not say "damaged." I would say developmentally delayed, or genetically retarded, or something. Also, I do not understand what a "self" is despite much study on the subject). The larger point is interesting to me. Everybody has psychological frailties and weaknesses. Everybody wants the external world to compensate for those - to patch those holes and gaps.

We usually are able to find a way, to find a niche, to find supports we need (a devoted spouse is a good one - and so is some money) and, worst case, booze and drugs can paper over lots of cracks in our walls. Oftentimes, people are only made aware of their weaknesses when the external supports are removed.

I have seen many people for consultation who I believed needed psychotherapy but whose world insulated them (or who arranged a life such that the world would insulated them) from the self-awareness and the discomfort. I never try to talk people into treatment: they need to feel the need and the inner disturbance to get help. If old Mr. Reality eventually gets through to them, I know they will come back.

However, people with personality disorders are fairly well-protected from Mr. Reality: they live in worlds of their own imagination. Instead of finding a way to make the world work for them, they just invent a world that suits them - and live in it unless or until it unravels.